Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00166590 Renewal 11/20/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(f)There is not documentation that the program specialist provided the assessment, completed 5/16/19 for Individual #1 to the plan team members for the ISP meeting held 6/20/19; therefore, compliance could not be measured. There is not documentation that the program specialist provided the assessment, completed 6/12/19 for Individual #2 to the plan team members for the ISP meeting held 9/9/19; therefore, compliance could not be measured. There is not documentation that the program specialist provided the assessment, completed 3/7/19 for Individual #3 to the plan team members for the ISP meeting held 4/10/19; therefore, compliance could not be measured. There is not documentation that the program specialist provided the assessment, completed 3/8/19 for Individual #4 to the plan team members for the ISP meeting held 4/5/19; therefore, compliance could not be measured. There is not documentation that the program specialist provided the assessment, completed 7/6/19 for individual #5 to the plan team members for the ISP meeting held 8/12/19; therefore, compliance could not be measured.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.Effective 12/4/2019, a standardized Assessment form is to be used by all 2390 Program Specialists. This form includes an area to record the date the assessments are being provided to the client and his/her team members. On 12/4/2019, All 2390 Program Specialists were retrained on regulation 2390.151 (f). The Director of Program Specialists will check all completed initial and annual assessments until no areas of non-compliance are noted for 3 consecutive months. In the event an area of non-compliance is noted, staff will be retrained and any errors of non-compliance will be documented and reported to the Compliance Officer. The Compliance Officer will randomly check a minimum of 10% of all annual assessments records once quarterly. [Documentation of all aforementioned checks shall be kept. (DPOC by AES,HSLS on 12/10/19)] 12/04/2019 Implemented
SIN-00127884 Renewal 01/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.40(c)Production Manager #1 did not have a record of training.Records of orientation and training, including dates held and staff attending, shall be kept on file.Training records for Staff #1 were reviewed. While training was not documented with other 24-hour staff training records, documentation for some training was found in other records. A total of 20 hours of training was documented in fire extinguisher and fire safety training, IM4Q overview, annual compliance training, First Aid/CPR/AED, Intellectual Disabilities Awareness seminar, and quarterly readings and discussion trainings. In order to complete the 24-hour training requirement, Staff #1 completed training in Dysphagia and Infections on 1/30/18 and cerebral palsy and basic sign language on 2/1/18.The Director of Operations completed a review of staff records to assure that staff had received the required 24-hours training. This was completed on 1/29/18. No other instances of non-compliance were found. To assure on-going compliance with this regulation, the HR Director has added Staff #1 to the list of staff who are required to complete 24-hour training. Several trainings have already been documented for this new training year. The HR Director will monitor Staff #1¿s training progress on the first day of each month through June 30, 2018, to assure that he is making progress in completing the 24-hour training requirement. This protocol is standard for all staff training documentation. [Within 30 days of receipt of the plan of correction, HR Director shall develop and implement a staff training record keeping and monitoring system to ensure records of staff orientations and trainings are kept and available for review upon request by the Department. (AS 2/12/18)] 02/08/2018 Implemented
2390.87Individual #1's most recent fire safety training was completed on 12/2/16.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.Fire safety training for Individual #1 was completed on 1/31/18. The Program Specialist staff were retrained in the requirements for fire safety training by the Director of Operations on 2/7/18. Program Specialist staff completed review of all records regarding fire safety training. No instances of non-compliance were found. This was completed on 2/8/18. This process was overseen by the Director of Operations. A process for monitoring compliance with the requirements for fire safety training was established on 2/8/18. On the first business day of each month, beginning in April 2018, the Compliance Officer will review records for all participants to ensure that the requirements for fire safety training are being met. Any non-compliance will be recorded and corrected. If no instances of non-compliance are found for six consecutive months, the monitoring will be discontinued. [Immediately, the Director of Operations shall develop and implement a tracking system to ensure all staff and clients are instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. Within 30 days of the development of the tracking system all staff person responsible for the timely completion of fire safety training shall be educated in the aforementioned system by the Director of Operations. At least quarterly for 1 year, the Director of Operations or designee shall audits the tracking system and a 10% sample of fire safety training records to ensure all individual are instructed in fire safety and the use of fire extinguisher, timely. Documentation of the audits shall be kept. (AS 2/12/18)] 02/08/2018 Implemented
2390.151(d)A program specialist did not sign and date Individual #1's assessment, completed 3/27/17.The program specialist shall sign and date the assessment.The Program Specialist signature was added to Individual #1¿s assessment. The Program Specialist staff were retrained in the requirement of signing the assessment by the Director of Operations on 2/7/18. Program Specialist staff completed review of all records to assure that they included the signature of the Program Specialist. No instances of non-compliance were found. This was completed on 2/8/18. This process was overseen by the Director of Operations. A process for monitoring compliance with the requirement for signing the assessment was established on 2/8/18. On the first business day of each month, beginning in April 2018, the Compliance Officer will review records for all participants to ensure that the requirements for signing the assessment are being met. Any non-compliance will be recorded and corrected. If no instances of non-compliance are found for six consecutive months, the monitoring will be discontinued. [Aforementioned review process shall be implemented upon hire of new program specialists. (AS 2/12/18)] 02/08/2018 Implemented
SIN-00086700 Renewal 11/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #1, admission date 3/2/15, had an initial assessment completed on 5/22/15.Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.The Program Specialist staff were retrained in the requirements for ISP initial assessments and annual updates by the Director of Operations on 12/15/15. Program Specialist staff completed review of records for ISP initial assessments and annual updates for other participants on 1/29/16. No instances of non-compliance were found. This was completed on 2/9/16. This process was overseen by the Director of Operations. A process for monitoring ISP initial assessments and annual updates documentation was established on 1/29/16. On the first business day of each month, beginning in March 2016, the Compliance Officer will review records of all participants to ensure that the requirements ISP initial assessments and annual updates documentation are being met. Any non-compliance will be recorded and corrected. If no instances of non-compliance are found for six consecutive months, the monitoring will be discontinued. [At least quarterly, a 25% sample of individual records shall be reviewed by the Director of Operations or designated staff person to ensure each client has an initial assessment and an annual assessment completed within the required timeframes. Documentation of all record reviews shall be kept.(AS 3/16/16)] 03/14/2016 Implemented
2390.151(f)The assessment for Individual #2, completed 6/1/15, was not sent to all plan team members. The assessment for Individual #3, completed 9/10/15, was not sent to all plan team members.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).Assessments for Individual #2 and Individual #3 have been sent to all plan team members. The Program Specialist staff were retrained in the requirements to send assessments to all plan team members by the Director of Operations on 12/15/15. Program Specialist staff completed review of records for sending assessments to all plan team members for other participants on 2/9/16. Assessments were sent to plan team members who were previously omitted for two participants. This was completed on 2/12/16. This process was overseen by the Director of Operations. A process for monitoring compliance with the requirements for providing assessments to all plan team members was established on 2/9/16. On the first business day of each month, beginning in March 2016, the Compliance Officer will review records for all participants to ensure that the requirements for providing assessments to all plan team members are being met. Any non-compliance will be recorded and corrected. If no instances of non-compliance are found for six consecutive months, the monitoring will be discontinued. [At least quarterly, a 25% sample of individual records shall be reviewed by the Director of Operations or designated staff person to ensure the program specialist provided assessments to all plan team members. Documentation of all record reviews shall be kept.(AS 3/16/16)] 03/14/2016 Implemented
2390.156(e)The program specialist did not notify the plan team members may decline the ISP review documentation for Individual #1, admission date 3/2/15. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.A letter of declination was sent to the plan team member who was omitted for Individual #1. The Program Specialist staff were retrained in the requirements of the option to decline the ISP review documentation by the Director of Operations on 12/15/15. Program Specialist staff completed review of records for the option to decline the ISP review documentation for other participants on 1/26/16. Letters of declination were sent to plan team members who were previously omitted for eight participants. This was completed on 1/29/16. This process was overseen by the Director of Operations. A process for monitoring ISP review documentation was established on 1/26/16. On the first business day of each month, beginning in March 2016, the Compliance Officer will review records of all participants to ensure that the requirements for the option to decline the ISP review documentation are being met. Any non-compliance will be recorded and corrected. If no instances of non-compliance are found for six consecutive months, the monitoring will be discontinued. [ISP review documentation including option to decline for Individual #1 was sent to family and PS on 11/17/15. At least quarterly, a 25% sample of individual records shall be reviewed by the Director of Operations or designated staff person to ensure the program specialist provided assessments to all plan team members. Documentation of all record reviews shall be kept.(AS 3/16/16)] 03/14/2016 Implemented
SIN-00055893 Renewal 10/17/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.81On 10/18/2013, the boiler storage room in the dining area was locked from the outside with a padlock. Stairways, hallways and exits from rooms and from the facility shall be unobstructed.The padlock and lock supports were removed from the storage room door. An existing lockset, which has a thumb lever on the interior, was repaired and put back into use. Photos sent via email to BHSL. The door can be locked from the outside, but the thumb lever on the inside overrides the lock and allows the door to be opened from the inside. The maintenance staff were retrained in this regulation. 10/22/2013 Implemented
SIN-00187792 Renewal 05/20/2021 Compliant - Finalized
SIN-00146980 Renewal 12/13/2018 Compliant - Finalized
SIN-00106763 Renewal 01/18/2017 Compliant - Finalized
SIN-00072077 Unannounced Monitoring 11/18/2014 Compliant - Finalized
SIN-00072607 Renewal 11/18/2014 Compliant - Finalized
SIN-00072511 Renewal 11/18/2014 Compliant - Finalized